Provider Demographics
NPI:1508846056
Name:FOREST LAKE PHARMACY
Entity Type:Organization
Organization Name:FOREST LAKE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANCIS
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:713-635-1441
Mailing Address - Street 1:9129 MESA DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77028-1606
Mailing Address - Country:US
Mailing Address - Phone:713-635-1441
Mailing Address - Fax:713-635-6810
Practice Address - Street 1:9129 MESA DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77028-1606
Practice Address - Country:US
Practice Address - Phone:713-635-1441
Practice Address - Fax:713-635-6810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-19
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11495333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX142918Medicaid